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APPLICATION FOR PERMIT SAN JOA ENVIRONMENTAL HN COUNTY EALTHH DIVISION IC HEALTH VICES �Y$� i�� ` sal 1601 E. HAZELTON AVE. , PHONE (209)468--3420 JeCC1 P 0 BOX 2009, STOCKTON, CA 95201 fJAY � j) $AIV0 ? s00i PFJWIT EXPIRES 1 YEAR FROM DATE 08410 OAQulfv CQ (Complete in Triplicate) 1RQVM 'Iek jCOUAiry nVTAL �qvt� Application is hereby made,to San Joaquin County for a permit to construct and/or install the work here $i,ee�I�ry,; . This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulat"fchf%frSan w Joaquin County Public Health Services. Job Address 16 Cherokee Lane City Lodi Lot Size/Acreage r t Owners dame Geweke Land Development Address lOfl5 S. Cherokee Lane Phone _. (916) Contractor -Wayne Drilling_ Address P• 0, Box 726, Lincoln LLicense No, 73 =14`_Phone6 —9 3 5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well Li4 DISTANCE TO NEAREST: SEPTIC TANK,. SEWER LINES DISPOSAL FLD. PROP. LINE + FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS h/� � �o• "�I x '3 h [I Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation 'r Dia. of Well Casing 2" C:l Domestic/Private EgGravel Pack ❑ Tracy Type of Casing PVC ___ Specifications SCh- 40 f'1 Public Other f 1 Delta depth of Grout Seal _,DDX 40' Type of GroutBent. Gement i I Irrigation ,5 Approx. Depth I I Eastern Surface Seal installed by Wayne Drilling Repair Work Done 0 Type of Pump H.P. State Work Done_ I Well Destruction © Well Diameter o+_ Sealing Material:& Depth Bent. cement (see work plan) Depth 95, Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will server Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of'soil to a depth of 3 feed Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED {_) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Numbet SUMPS LI Distance to nearest: Well Foundation Property Line T DISPOSAL PONDS I:1 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin county I Home owner or licensed agent's signature certifies the following: "i certify that in the performance of the work for which this permit is issued, I shall not k employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. ` Signed X_ Title: 2t@ f___geol ogi st Date: 426 I t ' FO PA NT USE ONLY ,�] t ow Application Accepted by Date t.` A y Pit or Grout Inspection Datf ction i + Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE i INFO AMOUNT DUE. AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. C(/'� y L r +fin . EH 13-2+tREv.,/X 5, L}„[ ,LIQ L� �, �3^- �b• 1 f'{{J7� EH t4-26